Compartment syndrome following intravenous regional anesthesia.

Abstract

To present two cases of upper extremity compartment syndrome following intravenous regional anesthesia. Case 1: A 57-yr-old man presented for surgical release of a left-hand Dupuytren's contracture. The procedure was performed under iv regional anesthesia with 360 mg lidocaine and sedation with 150 microg fentanyl and 1.5 mg midazolam. Tourniquet time was 107 min at a pressure of 260 mmHg using three different tourniquet sites. Within minutes of tourniquet release, increased forearm muscle tension, hand anesthesia, pallor, and limited motor function developed. Serum CK and myoglobin levels rose. Myoglobinuria was present. Several fasciotomies and aggressive fluid therapy were performed. Patient made almost full recovery. Case 2: A 73-yr-old woman with controlled hypertension had Dupuytren fasciotomy of her right hand under iv regional anesthesia with 200 mg lidocaine and sedation using 75 microg fentanyl and 1.5 mg midazolam. Tourniquet time was 64 min at a pressure of 250 mmHg using three different tourniquet sites. The patient complained of pain at the iv site during injection of local anesthetic, third tourniquet inflation and after deflation of tourniquet. Thirty minutes after arrival in PACU, her fingers were bluish. She complained of pain and swelling of the forearm. Under general anesthesia, fasciectomy was performed. Myoglobin and CPK levels rose. CPK MB was high but troponin was negative. Three days later she developed pulmonary embolism. She was heparinized and subsequently discharged home. She recovered completely. Compartment syndrome may have a rapid and severe onset. Etiology of our cases is still not established. We postulate that increased tissue pressure may be the cause. The anesthesiologists must be aware of compartment syndrome during regional anesthesia.